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Home My WebLink AboutBLD-19-003424 %F•Y•9R Unice Use Only z - 4'4.—A.-C9-CO 3 or; e O, Amount Permit expires 180 days from I issue date .. • EXPRESS BUILDING PERMIT APPLTrATiON 1 TOWN OF YARMOUTH RECEIVED . . Yarmouth Building Department 1146Route 28 DEC 05 2018 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING D PARTtdb:7 I - �J(, �I( n L� ay CONSTRUCTION ADDRESS: L%t) 2 (� Bo ckk 5 Akic .j} C1t5 ASSESSOR'S INFORMATION: • Map: Parcel: NAME PRESENT ADDRESS TEL it coNTRA.Groi: .i=uN P_OJI.utaC, Vt. SPU+.e'n`- Qi3. LIA.O..avtOrvt-u MA eiTh75 NAME MAILING ADDRESS TEL$..53% J S_ . C ,J btu() t Residential 0 Commercial Est Cost of Construction S lY►9-0 Home Improvement Contractor Lie.# (�n `7L�9 -7 Construction Supervisorlin # IO /9 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor l I have Worker's Compensation Insurance Insurance Company Name: "7::-. / MFY1 Gr43 Worker's Comp.PolicyeySJe,7 U r,95 q.S g 0 ` i cf WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: it of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 4 % ( f)Remove existing'(max.2 layers) Insulation Old Kings Highway/Historic[ � nDist � ( )Replacing like for like Pool fencing *The debris will be disposed of at 8404 .cc A 3s e-12 Location of Facility - I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief I understand that any false answer(s) will be just cause for d-.:: . • ..on of my license and . . . :on under MGL.Ch.268,Section 1. // ( 6 l /6 Applicant's Sig . .- _, _a — a L—_A Date: Owners Signature(or attachment) ;14D-4...•-j, (([J re.4.A.-f7 Date: T . 'c - ( R Approved By. ✓..4C.. Date: IV--c- 1 C? Building Official(or designee) EMAIL ADDRESS: Zoning District Ilistorical District 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District Within 100 8 of Wetlands: 0 Yes 0 No 0 Yes 0 No • 1 F c -te i�popwnoazwe iA djQ tIaooac/ueoet Attip \VV•?l Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration l Type: Individual ic= ( Registration: 128957 OLIVER KELLYExpiration: 06/13/2019 8 RHINE RD YARMOUTHPORT,MA 02675 r.' Update Address and return card. Mark reason for change. SCM C 20M-05/11 _----._—n Adnr•ee I"l Cenp...gl n Cmninumontlri Lewd Card - Office of Consumer Affairs&Business Regulation ( HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Aeairnatlon Expiration Office of Consumer Affairs and Business Regulation 128957 06/13/2019 10 Park Plaza-Suite 5170 Boston:it 02116 sem,-- E✓ C‘sci • - _--.- YARMOUTHPORT,MA 12675 • - Not valid without signature Undersecretary-• • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction.SUpdMsor Specialty CSSL-099167 - Expires:09/28/2019 — 1 _ OLIVER M KELLY ' ,/ 8 RHINE ROAD, YARMOUTH PORT MA 02676 ' 1 ANr c • C - -- Commissioner - A`� CERTIFICATE OF LIABILITY INSURANCE DATE (M DL e ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer tights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY °NN ,; nth: (508)775-1620 FAX No) ADDRESS: Isulfivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAICf HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER C: INSURER D: 8 RHINE RD • INSURER E: _ YARMOUTH PORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 316737 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITYPE OF INSURANCE IMO WYD POLICY NUMBER (MMrDD'YYYY) (MINDIYYYYY) WITS I TFI POLICY . COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ TED CLAIMS-MADE ❑OCCUR DAMAGS TO RENTED PREMISES(EaTED eminence) $ _ MED EXP(Any one person) $ N/APERSONAL ILADV INJURY $ — GENL AGGREGATE MIT APPLIES PER GENERAL AGGREGATE $ R POLICY❑JPECT fl LOC PRODUCTS-COMP/OP AGG $ — OTHER S 1 AUTOMOBRELWBIUTY COMBINED SINGLE LIMIT $ - (Ea accident) — _ ANY AUTO BODILY INJURY(Per person) $ ALL OS AUTOS OWNED _ SCHEDULED N/A _ BODILY INJURY(Pr accident) S NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident, $ $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ _ EXCESS LMB CLAMS-MADE N/A • AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER L. OTH- AND EMPLOYERS'LIABILITY /N X STATUTE ER ANYPROPRIETOR,PARTNERIEXECUTIVEWA E.L EACH ACCIDENT S 500000 A OFTICERMEMBEREXCLUDED? WA WA 6S62U68H08580918 05/10/2016 05/10/2019 (Menclawn/M NH) EL DISEASE-EA EMPLOYEE S 500,000 ryes describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD UR,Additional Remarks Schedule,may be attached x note specs Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for benefits to employees In states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy In force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govllwd/workers-compensationJnvestlgatlons/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Bernstein Builders ACCORDANCE WITH THE POLICY PROVISIONS. 139 NaMudcet Drive AUTHOR/ZED REPRESENTATIVE Chatham MA 02633 I �"� C� Daniel M.CroWley,CPCU,Vice President—Residual Market—WCRIBMA ®1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD =1.z The Commonwealth of Massachusetts • ft Department oflndustrialAccidents 1 Congress Street,Suite 100 • - Boston, MA 02114-2017 �141 'a.,;, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / () �� ik�/GS ( Please Print Legibly Name (Business/Organization/Individual): tk€1 l c—L<h-.4-t � 1Acc_ Address: ) 'n� kuj Qui _NO City/State/Zip: 1IkC (3.3Clk MA OO"1S Phone#: 50% SC. 1 4(o4{c) Are you an employer?Check the appropriate box: Type of project(required): 1.0(ern a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in8. Remodelingg any capacity.[No workers'comp.insurance required.] ❑ 3.0 era a homeowner doing all work myself[No workers'comp.insurance required]t 9. Demolition m 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.* 13.EriOOf repairs 6.0 We an a corporation and its officers have exercised their right of exemption per MGL e. EI Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box X I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. [Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Cr Ac P e Policy#or Self-ins. ' u,2 -Lic.#:CJS b 2 0 iO, % SCR",{�� C j, Expiration Date:qq C Job Site Address a)- *tV tT \ City/State/Zip: Lt 40-koa let PA- 0203 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci d.r the pains and peeperjury that the information provided above is true and correct Sirmature: ' a if`yc Date: 42 6 t� Phone 4: SOc5 So \ 4bMO Official use only. Do not write in this area, to be completed by city or town offciaL City or Town: Permit/License R Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: